Attachment, Complex Trauma and Behaviours that Challenge.

Transcription

1 Attachment, Complex Trauma and Behaviours that Challenge. Dr Cathy Harding Consultant Clinical Psychologist, Liberty Care, South Wales May BILD PBS Conference, Leeds.

2 What do we mean by Attachment An intimate relationship with a primary caregiver It is as important as food, shelter as provides us with protection, comfort and support Continues throughout lifespan. We need our attachment system more when we are frightened. As young children people work out how to make sense of behaviour and feelings dependent upon their care-givers Allows you to form blueprints about how to see your self and others (internal working models).

3

4

5 Children who are securely attached can rely on their caregiver to keep them safe and help them grow/develop. The learn their needs are important and others can help them. Children who do not develop secure attachments are more likely to adapt their attachment behaviours to develop strategies to help them stay close to their parent without risking further distress or rejection. They might be very suspicious or scared yet not use caregiver to seek support Can lead to miscuing. Children who receive frightening care will experience disorganisation of attachment responses where they seem unclear how to interact- parents are both reassuring and frightening.

6 Secure attachment might be harder in Learning disability. Evidence that the diagnosis of learning disability in itself changes the parental relationship and alters the interaction of attachment. High prevalence of Adverse Childhood Experiences Cognitive development rather than developmental stages (Piaget vs Viagotsky) Importance of secondary handicap (Sinasson, 1992) when our existence is reflected back to us tinged with contempt, disappointment, distance or not at all it has a profound effect on identity Greenhill, 2011

7 Risks to attachment when you need life long support Frequent changes in staff personal High workload of staff Discontinuity of staff presence Limited opportunities for individual support Organisational cultures which value independence from staff rather than mutual interdependence Lack of support for paid carers in negotiating relationship boundaries.

8 The impact of attachment disruption across the life span. Attachment Emotional regulation Empathy Pro- social behaviours Consistent, sensitive approach OR Dismissive, inconsistent responses Ability to monitor and adjust the duration and intensity of emotional reaction. Over arousal and overwhelming and so the focus is on reducing on distress To cope with stress To think of the needs of others To use others for support. Theory of mind

9 What Dan Hughes says..develop a rigid sense of self reliance which becomes a compulsive need to control all aspects of their environment.caregivers much be controlled if the (person) is to keep themselves safe (Hughes, 2004). Conference Jan 2016 in Edinburgh on YouTube

10 Blocking trust Young children block the pain of rejection by blocking the capacity for delight as their experience is that the world does not give delight/comfort/joy Intimidated by big feelings Hypervigilance to emotionally arousing situations Give up on learning new things Have negative bias Don t know safety ques Focus on objects/processions rather than relationships Block off their inner life (so can seem very distant)

11 Blocked care To protect against the rejection we block off the care Defensive and not open Focus on behaviours and not meaning Reactive and not proactive Repeat doing what is not working Look to correct not connect.

12 Neocortex Understanding the Biology Limbic system Diencephalon Brain stem Neocortex thinking brain Limbic system emotional development Diencephalon understanding of our bodies, movement, eating control etc. Brain stem - basic fight and flight/freeze

13 What might trauma look like? Aggressive or violent behaviours Self harm Refusal to cooperate or disobeying commands Withdrawal and sleeping at inappropriate times Hypersensitivity Sensation seeking Task avoidance Relationship avoidance Extreme attention seeking Poor social skills Big reactions to small events. Practice guidelines for trauma informed care and service delivery, Kezeler & Stravropoulos, 2012

14 What you might notice Poor turn taking Talking too much Not understanding some words or dissociation Misreading facile cues Difficulties with proximity/touch Preferring younger games Chaos within life, not learning from mistakes Hard to get to know/feel close to Odd reactions and behaviours. Lying - weird explanations Blaming others Playing people against each other Focus on immediate and not anting to talk about past Unable to reflect on incidents Compartmentalised memories Disproportionate behaviour.

15 So, what do we know about attachment and behaviours that challenge. What we know is that; Attachment insecurity/disorganisation as a risk factor for family/placement breakdown and so consideration of this is needed in our formulations. Promotion of positive, significant, enduring bonds with carers and others being a central goal of any intervention because without it there s risk factor for placement breakdown Case series show that attachment based behaviour modification has superior outcomes to standard ABA Considered the evidence from Schuengel et al 2011

16 Functions of behaviour Short term Escape/avoidance Attention Tangible Sensory Automatic Longer term Loneliness Control Power Self Esteem Pattison, 2016

17 Relationships are important What should be learned in early development is the ability to infer benign intent, which mitigates the negative experience and interrupts the aggressive responses Body of research that shows that regardless of the model the relationship is at the heart of successful changes. In non-learning disability literature increasing attention is being paid to the importance of trauma and early attachments in understanding adult distress. What should be learning in early development is the ability to infer benign intent which mitigates the negative experiences and interrupts the aggressive responces.

18 Relationships are Important and go both ways. Challenging behaviour generate powerful feelings: engaging in a relationship with people regardless of this is important These feelings exist in the here and now and over time They can become barriers to empathetic relationships: if unshared they can ; lead to toxic cultures developing and make it hard to provide good enough care.

19 Assessment integrating attachment & PBS Alan Skelly suggests: Functional assessment of behaviour Presence of insecure behaviour (MAST) Account of the emotional responses to behaviour (ambivalence, hostility, loving contact?) Assessing the conditions for security what s the last thing you did together/jointly When was the last time you had a really good laugh together?

20 Relational Risk Questions Does the behaviour threaten to break, damage or stress-load our working relationship? Do I feel hostile or ambivalent to the person I am working with? Is an earlier pattern of rejection and relationship breakdown happening again? Does the person seem fearful, unsure how to react to me, or show strange behaviours? Do I feel emotionally unavailable to or cut off from the person?

21 Different attachment styles

22 Attachment and PBS plans There are many ways to assess attachment and attachment behaviours, what matters most is that we consider it. Formulating in a way that helps to make sense of how the persons early experiences have lead to psychological vulnerabilities relationships difficulties and behaviours as a way of coping with these.to help make relationships more predictable. Each component of a PBS plan could include a statement about how this is helping the individual to form positive relationships and remove potential barriers to this (Skelly 2017). Attachment can be thought about within the PBS framework and how our primary, secondary and reactive strategies can help build attachments, mitigate against damaged attachments and repair when this occurs.

23 Meeting the needs of traumatised children (Golding 2017) Explore trauma and mourn losses Reliance and resources self esteem and identity Empathy and reflection managing behaviours in relation to others. Comfort and co-regulation gaining comfort from relationships with others Developing relationships Feeling safe emotionally and physically

24 Conceptualising this for staff teams. Stage 1 established relationships with the care/staff team using clear boundaries, contracts and crisis plans. Stage 2- embed these relationships using ideas around repair and ensuring all elements of emotional security and MDT Stage 3 help further develop emotional coping skills and more adaptive reponses. Stage 4 to continue providing this for the long term and enabling individuals to continue to use their emotions coping and relationship forming skills to develop and have a life worth living.

25 Attachments for staff Ones own attachment style Evidence is mixed; Secure attachment is a better awareness of others needs Anxious attachment personal distress is higher Avoidant attachment risk more detached and lack of empathy responses. Self compassion; directly relates to wellbeing. Some evidence that awareness of the others attachment style allows us to respond accordingly and PBS can be a vehicle for this.

26 Interventions Individual interventions Intensive interaction Dialectical Behaviour Therapy Theraplay Life story work

27 Strengthening attachments Create the conditions for Relational security Physical safety Emotional predictability Warmth Joyful mutual interactions Shared exploration Skelly, 2017 Emotionally aware care Core staff team Attuned care Consistency Reliability Demonstrate nurturing care Boundaries Shakleton, 2017

28 Service level interventions based on attachment Emphasis on service level change throughout documents. Skills and knowledge Environment and resources Policies and procedures Leadership and organisational change Jackson & Waters, 2015 Attachment informed mental health care ; Providing a secure base Continuity of care, availably and flexibility Sensitivity and responsiveness Providing corrective emotional experiences Moving on Bucci et al 2015

29 Staff Interventions Circle of Security Parenting Clear discussions about attachment How it feels supporting this person. PACE - (DDP, Dan Hughes) Integrative formulations Relationships expectations- coping strategies Debriefing Allow staff to have demonstrated the conditions for security (compassionate care agenda).

30 What else can carers do? Model emotional regulation and relationships Attune to the need underneath Be consistent and use a team approach/boundaries Teach and coach emotional regulation Positively support success Repair of ruptures to relationship. General mistrust not personal Stay in the game Know your hot buttons

31 Risks of not considering attachment Manage behaviour in short term but don t think about emotional skill development People increase the riskiness of behaviours and change the type of behaviour as the underlying need is not being met. That staff are burnt out and so do not remain in post for long therefore further damaging attachment relationships. Repeated breakdown of placement which again perpetuates the lack of attachments Attachments can be used as an outcome measures to measure the success of PBS plans.

32 People need to be provided with good enough care which is reliable, containing, empathetic and attuned. (Hughes)

33 Key resources Attachment and intellectual and Developmental Disability, Eds H.K. Fletcher, A Flood & DJ Hare In cooperating Attachment Theory Into Practice: Clinical Practice Guideline for Clinical Psychologist working with People who have intellectual Disabilities. The last frontier: Practice guidelines for treatment of Complex trauma and Trauma informed care and service delivery. Taking time Framework: A trauma informed framework for supporting people with intellectual disability (NSW)